Is it time G.I.D. got the A.X.E.?

It’s been nearly 3 years since my diagnosis of GID, and the anger of that moment hasn’t faded.

Only recently have I pried open my feelings to figure out why it angered me so. Wasn’t that what I was after? Hadn’t I known for months that I needed to transition, and finally a mental health professional was affirming that notion, albeit reluctantly and through gritted teeth? What more did I want?

At the time, I assumed I was just reacting to scornful and disrespectful treatment at the hands of an arrogant psychiatrist. That story is told elsewhere, so I won’t rehash it here, but suffice it to say that best practices in sensitivity were not followed.

Looking back, however, I think there is more to it. I felt like the diagnosis was giving me permission to transition, especially since it would open the way to taking female hormones, which I wanted to try.

Why should I need permission to be myself?

Therein lies the root of my uneasiness. To obtain medical care to smooth our transitions, we need a mental health counselor’s word that we are indeed the gender we think. To open a window into just how denigrating this cisnormative practice is, imagine a world where cisgender people needed their gender diagnosed to get medical care related to it. Where a man would have to convince a psychiatrist he was really male before being given Viagra. Where a woman would need a counselor to assert she was truly female before getting prescription-strength menstrual pain relief. Absurd, right? Yet isn’t that exactly what transgender people need to do — get the agreement of a mental health professional to allow us to be our gender — before getting medical care?

Why is it OK to require transgender people to, in effect, get “permission” to be our gender, but not to require cisgender people to do the same? Are we some lower form of human, who are presumed not to know our gender, while cisgender people, by virtue of their elevated status, don’t have their gender questioned?

Requiring a psychological diagnosis makes a statement for all the world to read that transgender people are not competent to know who they are.

Some might claim such professionals “look out for our interests”, though that in itself implies a paternalistic relationship. If someone is looking out for my interests, the assumption is they’re doing something for me I can’t do myself. That claim carries an implication of helplessness for transgender people. I’ve met a lot of transgender people, none of whom would I describe as helpless.

In fact, does it even make sense for a professional to deliver such a diagnosis? Would it ever be appropriate for a therapist to tell a competent, sane client who believed themselves to be trans that they aren’t? Would it ever be appropriate when a sane, competent client, clearly understanding what it meant to be trans, decides that they aren’t, for a therapist to tell them they are? Even unsure clients are generally encouraged to work it out for themselves. Are there any guidelines for gender therapists that encourage declaring with certainty that an uncertain client is or isn’t transgender?

Reality is that nearly all diagnoses of GID are self-diagnoses, with the counselor merely adding confirmation using an ability conferred upon them by some license or diploma. Yes, great therapists help people understand what is going on with their genders and what to do about it. That’s where gender therapists are most useful, not in verifying something they cannot know and can only take the client’s word for.

What’s the harm?

The requirement for obtaining a diagnosis isn’t a neutral one. It sucks time and money from transgender people who, preparing for their transitions, need as much of both as they can get. But that’s not the main problem.

What if we assumed people knew their own gender?

The main problem is that requiring a psychological diagnosis makes a statement for all the world to read that transgender people are not competent to know who they are. That we are less than cisgender people, who don’t need a diagnosis to be themselves. That we are more unreliable than the youngest of cisgender children, who, studies show, know their own gender as toddlers.

This assumption is codified into law and policy in a shocking number of ways. Want a driver’s license that accurately reports your gender? A social security account? A passport? You need a letter from a doctor confirming you’re allowed to be who you are. Unless you’re cisgender. Then you’re assumed to be able to figure it out for yourself.

Part of the problem is the nature of the diagnosis itself. GID. Gender Identity Dysphoria. Let’s leave aside for the moment, that many of us don’t suffer dysphoria. I didn’t. My experience was more one of euphoria at the possibility of being a member of my true gender, rather than any unhappiness living the way I was. No, the problem with GID is that it implies that you need some sort of problem to be “allowed” to medically transition. It’s not good enough simply to be who we are. We have to be miserable being someone else, before being allowed to be ourselves. Another thought experiment points out how silly that is. If someone wants to change careers, say going from software engineering to teaching like I did, would we require them to prove that they are clinically unhappy being an engineer? If someone no longer wants to be a New Yorker, and moves to Maryland, would we require a counselor to verify they are clinically unhappy living in New York? The fact is that in pretty much every other aspect of our lives, we’re considered competent to decide who we need to be. However, if you’re transgender, a professional must certify your gender.

So how should it work?

With a little imagination we can come up with alternatives.

What if we assumed people knew their own gender? If we decide we are male or female, our doctors and therapists take our word for it, the way they do with cisgender people. In other words, we are presumed just as competent as cisgender people to decide who we are. If we are looking for hormone or surgical treatment, we are not diagnosed by a therapist. Instead, a physician verifies that we indeed are lacking the physical characteristics that would make our body whole as a member of our identified gender, and that medical treatment would help. I.e. are our hormone levels too low for a female and need adjusting? Do we have breast tissue in excess of the norm for men, so surgery would be called for?

The diagnosis would simply be a statement of physical fact, as observed by a physician, instead of a commentary on our mood as observed by a counselor. The diagnosis would be something like “body out of line with identified gender” or Body/Gender Dissynergia, for those who insist upon medical terms that are difficult to spell. A doctor would diagnose by taking a blood test for hormone levels or doing a physical exam for anatomical parts. Our gender would not be up for professional evaluation. Gender therapists would exist solely to help us figure out what we want, not to pronounce us transgender. Perhaps in cases where a patient is suspected not to be capable of assessing their own condition, an evaluation of our competence might be in order, as it would for any such patient. But absent such impairment, transgender patients would no longer be asked to “prove” their gender in ways that cisgender patients are not.

Yes, it would require a substantial change in thinking on the part of the health community about transition-related health care. But, is it possible such a change is long overdue?

4 Comments

“I felt like the diagnosis was giving me permission to transition, especially since it would open the way to taking female hormones, which I wanted to try.”

Well that’s exactly right.

“Why should I need permission to be myself?”

You don’t. You are going through a psychological and medical triage to make sure you are getting the right care for the perceived affliction. Pretty much how most all psychiatric or medical conditions are resolved and treated.

“To obtain medical care to smooth our transitions, we need a mental health counselor’s word that we are indeed the gender we think. ”

Why is this unreasonable? There is no medical test where a physician looks at a chart or a brain scan and says, “Oh, yes, you are transgender.” There is a nebulous psychological component to the feeling of transgenderedness that even the patients themselves may not be able to resolve on their own, or may be overlaid with other serious psychological issues.

“Where a man would have to convince a psychiatrist he was really male before being given Viagra.”

Impotence can have psychological as well as physiological roots. A physician might very well refer a cis male to psychological counseling if they had a suspicion there was more to the problem than blood flow to the penis.

“The diagnosis would simply be a statement of physical fact, as observed by a physician, instead of a commentary on our mood as observed by a counselor.”

Gender identity is not an observable physical thing. It is a very subjective and personal perception.

” A doctor would diagnose by taking a blood test for hormone levels or doing a physical exam for anatomical parts. Our gender would not be up for professional evaluation. Gender therapists would exist solely to help us figure out what we want, not to pronounce us transgender.”

A blood test or physical examination doesn’t tell you anything about gender identity.

“What if we assumed people knew their own gender? If we decide we are male or female, our doctors and therapists take our word for it, the way they do with cisgender people.

Then the medical professionals would likely be sued out of business by some handful of patients who didn’t like the outcome of their treatment. What a transgender person desires is medical intervention, and that costs money and involves legal and medical risk. All of those things have to be reconciled in a business sense, Getting surgery or hormones is not magic fairy dust. They convey risk and they convey cost. I know you bristle at the concept of “gatekeepers”, but their existence is understandable.

“Why is it OK to require transgender people to, in effect, get “permission” to be our gender, but not to require cisgender people to do the same?”

This should be obvious. A transgender person asking to be recognized as something other than their biological sex is asking a for a momentous change in society’s norms and expectations, and asking individuals to endorse and accept that change. That is a lot to ask, and people often resent the attitude that something is wrong with them if they don’t get with the LGBT program.

That things have gotten to the point you CAN go to a therapist and get help, you CAN go to a doctor and get hormones, surgery, etc, you CAN go to the the DMV and SSA and get your gender changed, is enormous progress since even a generation ago.

I have never felt denigrated by health care professionals in the time I have sought counseling, laser/electrolysis, or hormones. Every professional I have dealt with has been supportive and non-judgmental. I’m sorry if you have had bad experiences.

Terri, all your experiences make sense and you make really good points when seen from a cisnormative point of view. In other words if you assume that cis identities are normal, and that trans identities require professional confirmation before they are valid, all your statements are perfectly logical.

It’s that mindset that I’m trying to cast light on. Assuming that cisgender identities are automatically valid whereas transgender identities require diagnosis puts cisgender people “above” trans people in that way. Asking “to be recognized as something other than their biological sex” is perfectly reasonable given the millions of transgender people whose identities are exactly that.

I do see your point. I would also like you to know that I am aware of your very positive and supportive presence on the forums. I very much admire you, and the level of commitment and love you give to the LGBT community.

The incidence of transgenderedness is only on the order of 1 in 10,000 males and 1 in 30,000 females, so clinically, yes, cis-genderedness is the norm. But that’s not your point, I think. Asking to be thought of as a normal human being is certainly what I would like to think of as being “reasonable”. On that we certainly agree.

Emotionally I side with you, but the hard reality is that medicine is both a science and a business. We are asking for medical intervention where there is no obvious physical defect. There is medical and legal risk that must be accounted for in the cost of providing this service. In this light, it is hardly surprising that psychological assessment is intrinsic to the process. I accept this, even though I don’t always like it. For example, I know I will be asked to do a year of RLE before being approved for SRS. I don’t want to do RLE with a penis under my skirt. I would feel extremely uncomfortable. There would be nothing “real life” about it, as far as I’m concerned. It’s my life and my body, and I resent being told how to undertake an enormously difficult task, brought with personal and professional risk, by a bunch of MDs and PhDs that have probably never been the special hell that being transgender can be.

The only solace I can draw form this whole situation is that there *is* a GID diagnosis, and there *is* a standard of care. The day I told my GP I was transgender was uncomfortable for me, but she didn’t bat an eye, and I left with a printout indicating a diagnosis of “Transgendered”. And I saw she selected it from a drop-down menu, lol! That told me we have come light years from even 20 years ago.

Thanks. I appreciate your kind words. I understand your point about about the business of medicine and the concern medical folks face about legal risk. I can see it from their point of view. (Though I claim that legal risk is a poor reason why our identities should be subject to anyone’s approval).

I would dispute the 10,000/30,000 figures. Those are based on outdated claims. The newest figures have it anywhere from 1 in 300 to 1 in 500. I work in a school with about 1500 students that always seems to have more than one trans student, so that would make the 10k/30k figures unlikely.